Skip to main content

Request for Leave of Absence - Completion Instructions

Items 1-7 must be completed as shown on the employee's current Personnel Action Form (UM 270)
  1. Name of employee for whom leave is requested.
  2. University assigned employee Identification number (EMPLID).
  3. Beginning date of employment with University.
  5. Current salary amount being paid to the employee; check the box to indicate whether the salary amount shown is annual or hourly rate.
  6. Title description as stated on the employee's current PAF.
  7. Employee's home department name and address.
  8. Check box(es) to indicate the type of leave requested.
  9. Enter the date on which the leave is to begin (MMDDYY) and the date on which the leave is to end (MMDDYY).
  10. Briefly describe the reason the leave is being requested.
  11. Street, City, State, and Zip Code for mailing address of the employee while he/she is on leave.
  12. Telephone number at which the employee can be reached while on leave, if available.
  13. If employee has previously been granted one or more leaves of absence from the University, enter the dates of the most recent leave. If there has been no previous leave, enter NONE.
  14. Check box(es) to indicate the type of leave taken during the period specified in item 13.
  15. Signature of the employee requesting leave. If the employee is unable to sign, responsible family member may authorize the request.
  16. Date on which leave request is authorized by employee or responsible family member. Request will not be processed until signed and dated by the employee or responsible family member.
  17. If the employee is an academic staff member, check the boxes that describe the employee's appointment type and employment terms.
  18. Enter the salary amount to be paid to the employee during the leave of absence period. If the actual amount is not known, indicate the approximate percentage of annual salary to be paid during the leave. If funding from other sources (non-University) is to be paid, report this in the "Comments" space. NOTE: For a RESEARCH leave, total compensation from all sources must equal full salary for the period.


Authorized signatures and date approved:

Required for all leave requests from Teaching and Research Staff:

Dept. Chairperson or Director


Chancellor, Vice President, Provost

Required for leave requests from Administrative, Service and Support staff: (Military, Personal, and Medical)

Dept. Chairperson or Director

Dean or Administrative Head


Reviewed 2020-05-04